Root cause analysis and strategies for reducing falls among inpatients in healthcare facilities: A narrative review

Abstract Background and Aims Root Cause Analysis (RCA) is a systematic process which can be applied to analyze fall incidences in reactive manner to identify contributing factors and propose actions for preventing future falls. To better understand cause of falls and effective interventions for their reduction we conducted a narrative review of RCA and Strategies for Reducing Falls among Inpatients in Healthcare Facilities. Methods In this narrative review, databases including Scopus, ISI Web of Science, Cochrane, and PubMed were searched to obtain the related literature published. Databases were searched from January 2005 until the end of March 2023. The Joanna Briggs Institute (JBI) tool was used for quality assessment of articles. To analyze the data, a five‐stage framework analysis method was utilized. Results Seven articles that fulfilled the inclusion criteria were identified for this study. All of the selected studies were interventional in nature and employed the RCA method to ascertain the underlying causes of inpatient falls. The root causes discovered for falls involved patient‐related factors (37.5%), environmental factors (25%), organizational and process factors (19.6%), staff and communication factors (17.9%). Strategies to reduce falls involved environmental measures and physical protection (29.4%), identifying, and displaying the causes of risk (23.5%), education and culturalization (21.6%), standard fall risk assessment tool (13.7%), and supervision and monitoring (11.8%). Conclusion the findings identify the root causes of falls in inpatient units and provide guidance for successful action plan execution. Additionally, it emphasizes the importance of considering the unique characteristics of healthcare organizations and adapting interventions accordingly for effectiveness in different settings.

Falls are a primary cause of avoidable injury in hospital and outpatient settings, 1 and can result in reduced mobility, functionality, and engagement in everyday tasks.Additionally, falls can contribute to longer hospital stays [2][3][4] and increased mortality rates. 2,3,5,6These incidents primarily affect frail patients, many of whom have dementia. 7Research indicates that the occurrence of falls can range from 1.7 to 16.9 falls per 1,00 patient days. 8,9Among patients over the age of 65, approximately one-third experience at least one fall per year. 10Furthermore, 20%-30% of falls result in moderate to severe injuries, 11 such as skin excoriation, fractures, dislocations, and head trauma.Various factors contribute to the risk of falls, including age, gender, comorbidities, physical and psychosocial impairments, and medication usage.These risk factors are applicable to both the general population and the elderly. 12,13Falls indeed create a substantial financial burden on the U.S. health systems, with an estimated $754 million in 2015 spent on medical expenses associated with fall-related fatalities. 14Furthermore, approximately 43% of these incidents result in harm to the patient. 15,16Approximately 14% of falls that occur in hospitals can be categorized as accidental due to environmental factors, such as slipping on a wet floor.Another 8% of falls are considered unpredictable, resulting from sudden disturbances in the patient's physical condition that affect their balance.The majority, accounting for 78% of falls, are deemed predictable. 17Potential factors that may contribute to falls include the introduction of new medications and alterations in medication dosage. 18ot cause analysis (RCA) was introduced in the healthcare industry nearly two decades ago.It is a methodical and structured approach employed to ascertain the fundamental factors that contribute to variations in performance.RCA serves as a widely accepted and standardized technique for pinpointing the causes of medical errors, thereby empowering healthcare establishments to devise strategies aimed at mitigating future errors. 19RCA has been widely employed within healthcare settings, particularly in hospitals, to systematically address the issue of falls. 20The primary objective of RCA is to identify and rectify the underlying cause of falls, thereby mitigating the likelihood of recurrence. 21It is important to note that the primary objective of the RCA process is not to assign blame to individuals, but rather to identify shortcomings in systemic processes, with the ultimate goal of preventing harm to patients, minimizing the occurrence of adverse events, and rectifying deficiencies. 22udies have shown that implementing a fall prevention program based on RCA can lead to positive outcomes for inpatients and enhance patient safety through subsequent interventions. 23,24While single and multi-component interventions are planned to reduce hospital falls, data on successful prevention programs are limited. 20 the other hand, narrative reviews play a crucial role in presenting a descriptive summary of a topic and conducting a subjective analysis of the literature.They are essential for synthesizing complex research evidence in a detailed and nuanced manner, particularly for topics requiring comprehensive analysis.Narrative reviews offer a flexible and practical approach to synthesizing diverse literature, making them valuable tools. 25,26Therefore, the aim of this narrative review study was to identify the causes of falls and strategies for their reduction within inpatient healthcare settings through RCA.'Reduce Falls,' 'Preventable Falls,' 'Decreasing Falls,' 'Patient safety,' Safety, Patient, Delivery, Problems."In order to increase sensitivity (to increase the selection of related articles), the researcher searched several databases with relatively common terms and synonymous words using the "OR" operator in the titles and abstracts of articles.In addition, to increase the specificity (to reduce the selection of irrelevant articles), we used "AND" operator.The search strategy is given in Table 1.In addition, to ensure a comprehensive search of articles, the references of selected articles were also reviewed.

| Inclusion and exclusion criteria
The following criteria were used as guidelines for screening articles.
The inclusion criteria for this study focused on selecting original English articles that employed RCA methods and were interventional in nature.Articles from Journals that did not have a rigorous evaluation process, book reviews, opinion articles, review articles, and letters to editor were exclusion criteria.

| Study selection
The studies obtained from the search were screened by two reviewers "RCA" OR "root cause analysis" #2 "Patient safety" OR "delivery" OR "safety" OR "patient" OR "Problems" #3 "falls" OR "reduce* falls" OR "decreasing falls" OR "patient falls" OR "preventable falls" the result was based on the agreement of these two reviewers.Third reviewer, Y.F., helped to reach a consensus regarding the disagreement.
Screening was performed using Endnote v.8.

| Critical appraisal
The Joanna Briggs Institute (JBI) tool was used for quality assessment of articles.We used the JBI Statement, which has a 9-item checklist, to ensure transparent reporting of studies.Each study was assessed by indicating "Yes," "No," "Unclear" or "Not applicable" for each item on the checklist. 27To prevent bias, the assessments were performed by two reviewers (Parvin Lakbala and Najmeh Bordbar), and a consensus was reached through Third reviewer, Yadolah Fakhri.

| Data extraction
According to the screened studies, the data were extracted to achieve the research goals and questions.For this purpose, first the data extraction form including the names of authors of the article, year, country of study, health setting, health units, type of study, study design, RCA participants, intervention period, fall reduction, fall causes and reducing strategies was designed.In the next step, one of the authors (Parvin Lakbala) extracted the data from the selected articles and the second author (Najmeh Bordbar) reviewed the data.
This form was designed and completed for each article in Excel 2013.

| Data synthesis
To analyze the data, a five-stage framework analysis method was utilized.In the first stage, the researcher repeatedly read extracted data from the included articles to become familiar with the data.The second stage involved forming repetitive ideas into groups of similar themes to identify a thematic framework.The third stage, indexing, focused on identifying units or clusters of data related to specific themes.Following indexing, the data were summarized in a table of themes based on the thematic framework.In the fifth stage, the data were combined, and maps and interpretations were used to clarify concepts, illustrate relationships between concepts, characterize the phenomenon, and provide explanations and suggestions. 28To ensure dependability, two members of the research team (Parvin Lakbala and Najmeh Bordbar) individually analyzed the contents and discussed the issues to reach a consensus.Ultimately, at the end of this process, the causes of falls and strategies for their reduction were identified.

| RESULTS
In the initial search, 255 articles were found and after removing duplicate and irrelevant articles, the abstract of 58 articles was reviewed.At this stage, 36 articles were deleted since they did not meet the inclusion criteria.Finally, after reading the full text of 22 articles, only seven articles were eligible for inclusion (Figure 1).
Table 2 presents the characteristics of the seven included studies.Studies were conducted in the United States 6 and Saudi Arabia, 1 published between 2008 and 2022.Four studies were conducted in a general hospital (inpatient units), 29,31,33,34 1 study in a children's hospital (mother and baby unit), 30 1 study in an acute care hospital (inpatient behavioral unit), 23 and 1 study in a level one trauma center (emergency department). 320][31][32][33][34] Most studies had established interdisciplinary quality improvement teams and committees to identify causes of falls, 23,[29][30][31]33,34 and only one study had revised an existing risk assessment tool. 32 Futher details of RCA participants and interventional period are described in Table 2.
Table 3 displays the specific categories for the reported root causes.
Causes such as medication/sedation, inappropriate footwear, unexpected movement, gait and balance limitations, patients under the influence of alcohol, and cognitive impairments (confusion, disorientation, memory deficits, and dizziness) were identified with higher frequency as contributing patient-related factors to falls. 23,29,30,32,34Various environmental factors have been identified in studies as contributors to falls.These include issues with toilets, tubs, and showers, equipment that poses tripping hazards, a noisy environment, wet floors, cold room temperature, bed/side rails, call lights not being used, crowded rooms, flooring problems, and poor lighting. 23,29,30,3432]34 Staff and communication factors can contribute to falls.]33

| DISCUSSION
Patient safety involves creating a safe environment and assessing the likelihood of incidents such as falls, medication errors, and infections.
On the other hand, RCA is a process that analyzes incidents in a reactive manner to identify contributing factors and propose actions for mitigation. 35But like any other method, they are not without limitations.RCA lacks a systemic perspective and implies a single, linear cause.Their inability to see the nonlinear causal mechanism among cause and effect relationships limits them to finding only one absolute root cause. 36,37The aim of this study was to identify the causes of falls and effective interventions for their reduction within inpatient healthcare settings through RCA.Indeed, since the included studies were conducted in various treatment facilities and units, it is expected that the causes of falls and the interventions and strategies employed to reduce them would vary.
The studies consistently found that factors related to the patient were the most frequently reported causes of falls.These factors played a significant role in contributing to fall incidents across the various studies.It's important to consider the results of these studies that highlight medication/sedation as a common cause of falls.
According to Najafpour et al's case control study, a combination of patient-related factors and medication history taken into account as risk factors for falls in hospital in-patients. 38In the study by Cioce et al, diuretic drugs were reported as the most common cause of falls with a frequency of 93.33%.To reduce the risk of falls associated with these drugs, recommend rescheduling their administration. 4In the study by Santana et al., it was found that 74.8% of fall patients had been prescribed sedatives, psychoactive, or antihypertensive drugs. 39According to Ribeiro et al's review, the use of central nervous system drugs increases the risk of inpatient falls, including anxiolytics, hypnotics, sedatives, antipsychotics, opioids, antiepileptics, and antidepressants. 40Various medications are linked to a notable risk of falls, known as "fall risk increasing drugs."Managing drug-induced falls is crucial for fall prevention, emphasizing the importance of considering the risk level of medications to optimize drug therapy in clinical settings. 41,42In the study by Weinberg et  Another intervention focused on modifying the administration protocol for furosemide.To reduce the need for nighttime voiding, furosemide was administered 3 h earlier, at 6:00 P.M.These interventions were aimed at minimizing the potential side effects and risks associated with these medications, ultimately reducing the likelihood of falls in the targeted patient population. 33e studies found that environmental measures and physical protection were the most frequently reported strategies.Addressing subsequent injuries. 30Additionally, high-risk patients were offered assisted toileting every 2 h during the day and whenever awake at night.This intervention aimed to address the increased risk of falls associated with the need for frequent toileting. 33 risk for falls by providing them with a yellow fall-alert bracelet and placing signs on the doors of their rooms.Additionally, they provided warm sweat suits as an alternative to traditional patient gowns, aiming to discourage the excessive use of blankets during patient ambulation, which can increase the risk of falls.Furthermore, wireless bed and chair alarms were purchased and utilized for impulsive patients to provide timely alerts and prevent falls. 23In the Kuwaiti and Subbarayalu study, they implemented bed alarm systems and utilized orange stickers/fall risk signs in common fall risk zones within the hospital.These measures were implemented with the goal of reducing falls among patients.Bed alarm systems are designed to alert healthcare providers when a patient attempts to leave the bed without assistance, helping to prevent falls.The use of orange stickers or fall risk signs in specific areas serves as a visual reminder for both patients and staff to exercise caution and take necessary precautions in those areas.By implementing these strategies, the study aimed to enhance patient safety and minimize the incidence of falls in the hospital setting. 31In the study by Boot et al., they developed an assessment tool to identify high-risk patients, used wristbands to identify those at risk of falling, and emphasized increased observation for patients prone to falls. 43entifying and displaying the causes of risk were the second frequently reported strategies.3][34] In this regard, various intervention initiatives were T A B L E 4 Strategies used to reduce falls in included studies.

Environmental measures and physical protection
− increasing the safety of toileting and mobility 29 − reduction of potential injury due to a fall by mothers' bed type and bed height 30 − implement physical preventive interventions including bed rails up, removal of tripping hazards, assuring awake and alert caregivers. 30− implementation precautions to minimize injury from falls 30 − All patients at risk for falls were identified with a yellow fall-alert bracelet and signs on the door to the patient's room. 23 Provided warm sweat suits as an alternative to traditional patient gowns to discourage blanket usage during patient ambulation. 23− Wireless bed and chair alarms were purchased for use with impulsive patients. 23 bed alarm systems 31 − orange sticker/fall risk sign in the common fall risk zones in the hospital 31 − apply a green fall risk bracelet for patient 32 − Conducted orientation for inpatients and their significant others on the unit's environment and personal equipment, such as call bells, phones, and urinals.33 − use of bed and chair alarm 33 − high-risk patients be offered assisted toileting every 2 h during the day and at night whenever awake.33 − having patients put on their call light when they went to the bathroom 34 − using informative signs in the patient room 34 15 (29.4)   tifying and displaying the causes of risk − Implementation of electronic dashboards to displaying real-time unit-specific falls rates 29 − Implementing a transparent root-cause analysis process after falls 29 − increased Patient and family engagement by including them in post-fall huddles 29 − Highlighted patients' fall risks on nurses' station whiteboards for easy visibility.23 − Incorporated fall risk levels and factors into patient handoff.23 − information about current fall risk status to staffs by power chart displaying fall status 31 − Bulletin boards in the staff break room and in the locker room were used to post a copy of the new tool 32 − A notice about the reduction of falls was also placed on the ED dashboard.32 − When a fall occurred, a post-fall mini-root cause analysis was conducted with the entire nursing staff 32 − Nurse managers conducted in-service meetings emphasizing fall prevention and lessons learned from fall reviews.33 − Post fall Assessments by root causes of each fall 33 − patients and their family members, as well as staff, have contributed useful information toward finding the cause of initial falls that can be used to prevent subsequent falls. imemented, including placing notices on unit dashboards to highlight the reduction of falls, 32 highlighting patients' fall risks on nurses' station whiteboards for easy visibility, incorporating fall risk levels and factors into patient handoff, 23 holding daily contests for the lowest number of consecutive fall-free days, 33 implementing electronic dashboards to display real-time unit-specific falls rates, and soliciting staff feedback on barriers to falls prevention.29 Ineffective communication among healthcare team members can result in important information about a patient's fall risk assessment not being properly shared, leading to a lack of awareness and failure to implement preventive measures.When staff members do not feel accountable or responsible for adhering to fall prevention protocols, there is a higher likelihood of gaps in implementing preventive measures, increasing the risk of falls.patients' knowledge and self-perception of risk, empowering them to take proactive measures to reduce their risk of falling while in the hospital. 45ne study found that several key factors were identified as helpful in promoting effective patient education.These included providing individualized and consistent education, using small interactive groups, and adopting a patient-centered multi-factorial approach.46 The findings of a systematic review and meta-analysis demonstrated that educating patients and staff significantly reduces the occurrence of bed falls in the hospital setting.This highlights the effectiveness of training interventions in preventing such incidents and promoting patient safety.47 In addition, according to clinical practice guidelines patients and residents should be screened for fall risks upon admission to the hospital.

| LIMITATIONS
This study has some limitations.As mentioned, due to the limitations of the RCA method, including only studies that used the RCA was one of the major limitations of this study.Secondly, it is difficult to determine which actions were responsible for the reduction in falls, T A B L E 4 (Continued)

Categories
Strategies Frequency N (%) Standard fall risk assessment tool − Employing standardized Morse Fall Risk Assessment tool 29 − standardize methods of assessing newborn fall risk 30 − risk factor assessment of falls within 24 h of admission by Morse Fall Scale (MFS) 31 − incorporated additional measures into their ED fall assessments 32 − embedded the new fall assessment tool into the triage note 32 − Fall Risk Assessments On admission 33 − completion of the initial fall risk assessments and implementation of fall prevention measures 34 7 (13.7) Supervision and monitoring − Revised staff workflow to allow the unit staff to maintain a constant presence in the common area. 23− monitoring patient medications 29 − Restriction of Use of Diphenhydramine, Hydroxyzine, and Furosemide 33 − Rounding protocol 31 − All at risk patients must have either an exit alarm or a constant observer. 32 volunteers (college students) were trained to round on fall risk patients 32 6 (11.8)

2 | METHODOLOGY 2 . 1 |
Search strategy In this narrative review, databases including Scopus, ISI Web of Science, Cochrane, and PubMed were searched to obtain the related literature published.Databases were searched from January 2005 until the end of March 2023.The search strategy included the following keywords: 'RCA,' 'Root Cause Analysis,' Falls, 'Patient falls,'

(
P.L and N.B) separately in three stages (title, abstract and full text), and T A B L E 1 The search strategy.Search Engines and Databases: Scopus, ISI Web of Science, Cochrane, and PubMed Limits: Language (English) and only original research Date: January 2005 -March 2023 Strategy: #1 AND #2, #1 AND #3 #1 al., specific interventions were implemented to address falls related to medication use.One intervention involved restricting the use of diphenhydramine and hydroxyzine in patients aged 65 and above.
these factors is crucial in reducing the risk of falls and promoting a safer environment.In the study conducted by Whatley et al., they implemented measures to reduce the potential injuries caused by falls.These measures included considering the type and height of the mother's bed, implementing physical preventive interventions such as having bed rails up, removing tripping hazards.These interventions aimed to create a safer environment and minimize the risk of falls and

T A B L E 3 34 − delivery-related complications and postpartum state 30 − hesitancy to accept help 30 − 34 −tripping on blankets 23 − 32 − bowel/bladder problems 34 − 34 −− 23 − 23 − 31 − 31 − 32 − 32 −− frequent interruptions prohibited adequate rest 30 − 23 , 29 − 31 − 32 − 30 , 33 −
Causes of falls occurring in inpatient units.Gait, balance limitations,23,Patients patients under the influence of alcohol,23,changes in clinical condition/electrolyte imbalance confused/disoriented/memory deficits/dizziness, Lack of patient visibility from nurses' station Rapid Response Team not called post fall orange sticker/falls risk sign was not used hourly rounding did not happen, 30,inappropriate or inadequate use was made of the bed alarms/ tab alarms/call bells, 31,The incompleteness of the fall risk assessment tool, 31,falls risk assessments were not routinely completed at admission, Lack of team communication regarding fall risk assessment and interventions, details of high fall risk patients were not interchanged between nurses during hand over patient would go to bathroom/toilet without assistance, 31,Inadequate staff accountability to follow fall prevention protocols, Inadequate safety awareness by staff,

34 12 ( 23 . 5 ) 34 11
Education and culturalization− Facilitating organization-wide education29 − soliciting staff feedback on barriers to falls prevention29 − educate parents and staff about the risk of newborn falls30 − Implemented unit-wide staff nurse education module on proper utilization of the Morse Fall Scale (MFS)23 − training to staffs31 − department-wide education to introduce a revised ED fall risk assessment32 − Creating a culture of fall prevention 32 − Provided hands-on and videotaped fall prevention training to resident and attending physicians, rehabilitation medicine therapists, housekeepers, and transporters. 33− Daily contests for the lowest number of consecutive fall-free days were held33 − training staff in proper lifting techniques and how to transfer patients34 − re-education of the staff Additionally, a lack of sufficient training or education on fall prevention strategies and maintaining a safe environment can contribute to inadequate safety.By prioritizing education, culturalization, and clarity, healthcare organizations can enhance staff knowledge, promote cultural sensitivity, and improve communication practices.These efforts contribute to a safer environment, reduced falls, and improved patient safety outcomes.staff training, 23,29-34 In the study by Paulino et al., it was found that aspects related to the health work process, such as teamwork, professional skills, and nursing care execution, are the main contributing factors to falls.Effective teamwork, proper skills and training, and adherence to protocols are crucial in preventing falls and improving patient safety. 44In a review study conducted by Heng et al., it was found that hospital falls prevention interventions that include patient education can effectively reduce falls and associated injuries like bruising, lacerations, or fractures.The success of these interventions is influenced by factors such as the design, delivery method, and quality of educational programs.Well-designed education programs have shown to improve Multifactorial interventions based on individual risk factors are strongly recommended in hospitals, as they significantly reduce falls.Patients at risk of falling should receive training and advice on fall prevention measures.Caregivers should also receive active educational interventions to increase their knowledge and prevent residents from falling. 485 | CONCLUSION Multiple factors, such as patient-related, environmental, organizational and process, staff and communication factors, contribute to the occurrence of falls in hospitalized patients.Identifying and addressing these factors is essential for preventing falls and ensuring patient safety in healthcare settings.Each healthcare organization has its own unique characteristics and processes, so while certain solutions and strategies have been effective in reducing patient falls in one facility, they may not work the same way in another organization.It is important to consider the specific context and adapt interventions accordingly to ensure effectiveness in different healthcare settings.